Provider Demographics
NPI:1306070446
Name:MACKEY, BRANDI ADELE (IDMT)
Entity type:Individual
Prefix:MRS
First Name:BRANDI
Middle Name:ADELE
Last Name:MACKEY
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 KURSTEN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-4646
Mailing Address - Country:US
Mailing Address - Phone:505-264-9784
Mailing Address - Fax:
Practice Address - Street 1:84 BOMBER RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-5272
Practice Address - Country:US
Practice Address - Phone:208-828-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians